Management of Dysphagia in Patients with Achalasia and Severe Cardiac Insufficiency

Initial Urgent Evaluation

The American College of Cardiology recommends that patients with dysphagia and achalasia be kept NPO (nothing by mouth) immediately and evaluated urgently for aspiration risk using videofluoroscopy (VFSS) or fiber optic endoscopic evaluation of swallowing (FEES) 1, 2
Clarify whether dysphagia is for solids only or for both solids and liquids, as this is crucial for differential diagnosis, with progressive dysphagia starting with solids and then including liquids indicating mechanical obstruction, while simultaneous involvement suggests motility disorder or neurological cause 3, 2
Mențineți pacientul NPO până la evaluarea formală a deglutiției, având în vedere vârsta înaintată și comorbiditatea cardiacă severă, as 55% of patients with aspiration present with silent aspiration without protective cough reflex, making clinical examination alone insufficient 2, 3

The American Heart Association recommends urgent videofluoroscopy (VFSS) or FEES for evaluation of swallowing mechanics and aspiration risk, with VFSS being the gold standard for evaluating bolus manipulation, tongue movement, hyoid/laryngeal elevation, pharyngeal constriction, and aspiration 1, 2
FEES allows for direct visualization of pharyngeal/laryngeal structures and management of secretions at the bedside 1
Perform esophagram with barium (barium swallow), which has a sensitivity of 96% for esophageal cancer and 80-89% for motility disorders such as achalasia 3

Implement immediate compensatory strategies, including postural techniques (chin-down posture), dietary modifications according to the IDDSI framework, and rigorous oral hygiene 1
Consult a dietitian immediately to prevent malnutrition and consider enteral nutrition for patients with unsafe oral intake or severe weight loss 1
The American College of Cardiology recommends that patients with severe cardiac insufficiency (NYHA IV) and multiple comorbidities be carefully evaluated for the risks and benefits of enteral nutrition, as mortality associated with tube feeding is significant, ranging from 35-63% at 6 months and 52-84% at 1 year 6

Provide restorative swallowing therapy, including exercises for lingual resistance, breath-holding, and effortful swallowing to improve pharyngeal pressure generation 1
The Shaker exercise (repetitive and sustained head lifts in the supine position) has shown significant improvement in upper esophageal sphincter opening and resolution of aspiration 4